Gastroesophageal reflux (GER) is a major problem with serious consequences in both the pediatric and adult population. GER includes reflux or regurgitation of stomach contents up into the esophagus. Occasionally the stomach contents, including acids, are aspirated into the pulmonary tree. GER is especially serious in infants, but many adults are also troubled with the symptoms. Frequent complications include esophagitis and esophageal stricture, intractable vomiting, asthma, and aspiration pneumonia. In infants and children GER has been associated with a wide spectrum of symptoms including vomiting, failure to thrive, recurrent aspiration pneumonia, apnea, sudden infant death syndrome, and brain damage. There is also a high incidence of GER in patients who have undergone correction of esophageal atresia or abnormal esophageal narrowing.
The gastroesophageal junction (GEJ) is an anatomical region including the junction of the stomach and esophagus. The GEJ combined with the lower esophageal sphincter (LES) forms a valve between the stomach and esophagus. The LES is formed of circular bands of muscle at the distal esophagus near the stomach. Incompetence of the valve contributes to symptoms of GER. In the last three decades improved understanding of the pathophysiology of GER has led to development of a variety of surgical procedures designed to construct a competent valve at the GEJ. Although usually effective, all are associated with significant morbidity and the risk of recurrence.
Fundoplication is a surgical treatment for GER. This corrective surgery typically involves a major operation with a large incision to expose the stomach and lower esophagus. Without penetrating the stomach, the esophagus is pulled down below the hole in the diaphragm through which the esophagus is normally admitted. Then a portion of the stomach, the fundus, is plicated or gathered up and wrapped around the distal end of the esophagus and sewn in place from the outside of the stomach and esophagus. FIG. 1a is a schematic of a conventional fundoplication of a stomach 2 to an esophagus 4. Suture line 6 represents surgical fixation of folds 8 to create the fundoplication. Folds 8 are in the fundal region of stomach 2. Folding the fundus up and around the distal end of esophagus 4 forms the fundoplication. The stomach lumen 10 is not entered. Suture line 6 holds folds 8 in place; it does not represent repair of a gastric incision.
Some current anti-reflux procedures are the Nissen, Thal, and Belsey. All these procedures require an abdominal or thoracic incision to wrap the stomach around the esophagus. The Belsey can require surgical removal of part of a rib. Each procedure takes about two hours to perform and they are attended by significant morbidity and mortality. In addition to being lengthy surgical procedures, spontaneous undoing of the plication is a major problem. Slippage has been the major cause of operative failures.
The most commonly performed operation for correction of GER in infants and children has been the Nissen fundoplication. The Nissen is associated with postoperative complications of small bowel obstruction, paraesophageal hernia, wrap slippage, and the gas-bloat syndrome. Although another procedure, Thal fundoplication, appears to have fewer postoperative complications, it has not been as widely used due to a higher rate of recurrent GER.
Successful techniques for the surgical treatment of gastroesophageal reflux appear to have several features in common: 1) lengthening of the indraabdominal portion of esophagus, 2) decreasing the angle of His, 3) construction of a valve mechanism at the GEJ, and 4) forming a complete or partial gastric wrap around the esophagus to augment extra-esophageal pressure (pressure originating outside the esophagus and acting on the esophagus). Recent technical advances in endoscopic surgery allow performance of a growing number of operations a minimally invasive manner.
A schematic of a conventional flexible endoscope 1 is shown in FIG. 1B and a cross-sectional area of its insertion tube 21 is shown in FIG. 1C. Endoscope 1 typically includes a depressible button 3 to control air and water influx, a control 5 to manipulate suction, and a control head 7. A biopsy channel inlet 9 is typically located on control head 7, as is an eye piece or viewing aperture 11. Endoscope 1 communicates with an external air and/or suction device through end 13 and to an external light source through end 15. Knob 17 controls up and down deflection of a flexible tip 23 at the distal end of insertion tube 21 and knob 19 controls left/right deflection of tip 23. A cross-sectional view of insertion tube 21 includes a lens 25, a light source 27, an air and water channel 29, and a biopsy and suction channel 31.
In use, the operator inserts distal tip 23 down the esophagus of an anesthetized patient and into the patient's stomach. The operator can manipulate control knobs 17 and 19 to view an area of interest. Air and water can be injected into the patient's stomach to assist in viewing an area clearly. Air, water and other fluids can be removed by use of the suction. The availability of flexible fiberoptic endoscopes has facilitated the development of new surgical procedures and approaches.